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e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 14, Issue 12 Ver. II (Dec. 2015), PP 109-115
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Abstract:Human immunodeficiency virus infection (HIV/AIDS) have given more importance to tuberculosis,
which was discovered a century ago.HIV infection is the most important factor for the development of
tuberculosis. Initially Pneumocystis carinii pneumonia among homosexual men was discovered. The risk for
patients with AIDS developing TB is 170 times higher and risk for death reported to be twice that HIV infected
patients without TB.HIV infection suppresses the immune system, making patients susceptible to opportunistic
infections (OIs), with high mortality worldwide. Latency and reactivation of tuberculosis is similar to
reactivation of Burkholderiapseudomallei,cryptococcosis, and histoplasmosis. Cellular immunity impairment is
a predisposing factor to development of clinical disease. Patients with CD4-Tcell counts(>200-300 mm3)
generally will have classic TB,with apical cavitary lung disease, respiratory symptoms, fevers weight loss.TB
may accelerate the progression of HIV infection by activating expression of HIV from macrophages and immune
reconstitution syndrome(IRIS).Patients with advanced pretreatment immunodeficiency had persistently
increased risk of TB during HAART ,this may reflect limited capacity for immune restoration among such
patients. Four drugs are recommended e.g.,INH,330 mg orally, rifampin, 600 mg orally daily ,pyrazinamide 20
to 35 mg/kg orally daily, and ethambutol 15 to 25 mg/kg daily.Frequent treatment for MAC include macrolides,
with rifampin or ciprofloxacin added.CDCrecommendations for diagnosis, treatment and prevention of HIV-TB
coinfection are beneficial.
Keywords:Tuberculosis,HIV infection, Pathogenesis, and Treatment
I. Introduction
In 1882 Robert Koch discovered Mycobacterium tuberculosis. There is evidence of spinal tuberculosis
in Neolithic, pre-Columbian and early Egyptian remains. In the early 17th and 18thcenturies, tuberculosis caused
one fourth of all deaths in Europe. The modern era of tuberculosis began in 1946 with the demonstration of the
efficacy of streptomycin(STM),and the availability of isoniazid(INH) in 1952,made tuberculosis curable in most
patients and addition of rifampin(RMP) in 1970 allowed for even more effective combination
therapy[1].Tuberculosis(TB) continues to be a devastating disease worldwide, It is estimated to cause 3 million
deaths annually[2,].In 1981,initially five cases of Pneumocystis carinii pneumonia among homosexual men
were diagnosed and reported by the clinical investigators[3].Acquired immunodeficiency syndrome(AIDS) was
first recognized in 1981[3].Human Immunodeficiency virus infection(HIV) is far by the most important
predisposing factor for the development of TB.Experts believed that TB accounted for 30% of 5.0 million
AIDS-related deaths in the year 2000[4].The risk for a patient with AIDS developing TB is 170 times higher
than for a non-immunocompromised person. The risk for death in HIV-infected patient with TB was reported to
be twice that in HIV-infected patients without TB, independent of CD4 cell count [5].The hallmark of infection
is immune suppression. Making patients susceptible to opportunistic infections (OIs)[6].In 2013 of the estimated
9 million people who developed TB an estimated 1.1 million(13%) were HIV positive ,and there were360,000
deaths from HIV associated TB equivalent to 25% of all TB deaths, and around 25% of the estimated 1.5
million deaths from HIV/AIDS[7].Clinical presentation depends largely on the overall immune status of the
patient. Patients with CD4 cell counts (>200-300/mm3) generally will have classic TB. [8].Diagnosis include
cavitary lung disease, respiratory symptoms, fevers and weight loss, demonstrations of M,tuberculosis in
sputum smear for acid-fast bacilli(AFB),cultures using radiometric system ( BACTEC)[8,9].The introduction of
highly active antiretroviral therapy (HAART) has exerted a profound effect on the epidemiology, naturalhistory,
clinical manifestations, and responses to treatment of 0Is[10].Centers for Disease Control and Prevention(CDC)
recommends early diagnosis, effective treatment of TB-HIV infected patients are critical for curing TB,
minimizing the negative effects of TB on the course of HIV and preventing the transmission of Mycobacterium
DOI: 10.9790/0853-14122109115
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II.Epidemiology
Tuberculosis (TB) has been an affliction of humankind since before recorded history. Inspired writers
such as John Bunyan to aptly describe this deadly and mysterious disease in 1660 as the captain of all these
men of death that came against him to take him to the grave[11] In the United States,.M.tuberculosis(MTB)
infects an estimated 1.5 million persons. Tuberculosis reemerged between 1985 and 1992 and approximately
67,000 more cases occurred than would have been estimated had the earlier rate of decline continued[4].Each
year since 1992 the number of tuberculosis cases have declined to 16,377 in the year 2000 for a rate of 5.8 cases
per 100,000 population, and approximately 25 % to 30 % were HIV co-infected[12,13]The groups with greatest
increases in rates of TB,especially black and Hispanic men 25 to 40 years of age, are also the groups with
highest rates of HIV infections demonstrating how closely intertwined these two epidemics have
become[9].Anonymous HIV testing of serum from TB clinics demonstrated that as many as 40% of all TB
patients are HIV infected[14].This among AIDS-related 0Is because it is contagious to otherwise healthy
persons. This combined with several nosocomial outbreaks affecting both patients and staff [15], has led to
extensive reconsideration of hospital infection control efforts [16].Finally, resistant TB has been increasing,
especially in urban areas, and is particularly difficult to treat in the HIV-infected patient [17].At the same time
the number of foreign-born persons with tuberculosis, and their proportion of the total cases, have continued to
increase. Disease risk is highest within the first years after immigration[9].The control of tuberculosis in
foreign-born individuals will be of major importance in meeting the goals for eliminating tuberculosis in
U.S.[9].Tuberculosis remains tremendous problem outside United States. It is estimated that one-third of the
worlds population, almost 2 billion persons, is infected with M.tuberculosis.For this reservoir come 8 million
new tuberculosis patients and approximately 3 million deaths each year[12].Thus,95% of tuberculosis disease
occurs in the developing countries, where there are few medical or public health resources and where
concomitant HIV infection is common[12].
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V. Clinical manifestation
Clinical manifestation depends largely on the overall immune status of the patient[8].Patients with high
CD4 counts(>200-300 mm3),generally will have classic TB,with apicalcavitary lung disease, respiratory
symptoms, fevers ,weight loss[8,].As immunity wanes, presentations become less specific, and diagnosis
become more difficult as atypical chest radiographic features and extra pulmonary TB are encountered. The
most common extra pulmonary manifestations are asymmetric lymphadenopathypericarditis,pleurisy bone
disease,and skin lesions/Fever weight loss, and fatigue may be the only symptoms with disseminated TB,
mimicking lymphoma,CMV disease, AIDS wasting syndrome,MAC ,and other diseases[5].Hilar or mediastinal
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VII. Treatment
CDC and the American Thoracic Society guidelines recommend that the minimal duration of therapy is
6 months for drug-susceptible TB in patients co-infected with HIV.If clinical or bacteriologic response is slow,
they recommend treatment for a total of 9 months, or 4 months after culture becomes negative[9].Four drugs are
recommended e.g., INH,300 mg orally ,rifampin 600 mg orally daily, pyrazinamide 20 t0 35 mg/kg orally daily,
and ethambutol 15 to 25 mg/kg orally daily.Patients on HAART may experience drug interactions between
rafamycin and protease inhibitors and other commonly used agents. Rifampin induces the activity of
cytochrome P450 CYP3A, which lowers the concentration of protease inhibitors and non-nucleoside reverse
transcriptase inhibitors, resulting in incomplete viral suppression[59].Most experts, however advise against
withholding ART until completion of TB therapy. Three facts for treatment of TB in HIV infected patients
must be noted that include:
(i)ART should be administered when indicated
(ii)a short course regimen(6-9 months, dependent on the regimen) should be administered as directly observed
therapy to enhance compliance, and
(iii)Rifabutin,at a lower dose (150 mg) is preferred over rifampin because of significant drug interactions of
rifampin with protease inhibitors and-non-nucleoside reverse transcriptase inhibitor.
Patients with CD4+-T-cells counts of less than 100/L should receive daily therapy for first 2 months, and no
less often than three times weekly during the remaindertreatment. This will minimize the risk of rifampin or
rifabutin resistance developing on less frequent intermittent regimens [60].Sputum culture and smear should be
checked monthly to document clearing of infection. Persistent fever for more 2 to 4 weeks in a patient receiving
standard for drug regimen suggests multi drug resistant TB(MDR TB).If susceptibility results are pending,
treatment options should be guided by prior drug exposure, history of exposure to a case of MDR TB and the
susceptibility patterns in the community. Drug fever and second infection should also be considered [14,61,].
Prophylaxis.Chemoprophylaxis with INH(300 mg daily) for 9 moths should be administered to any HIVinfected patient with a tuberculin skin test induration that is at least 5 mm in diameter, once active TB has been
ruled out.Chemoprophylaxis also should be initiated regardless of the tuberculin test in patients with history of
positive results who were not adequately treated, a close contact with TB.Recent studies have shown that the
results of anergy testing are not reproducible and that INH prophylaxis does not reduce the incidence of TB in
HIV-infected patients with anergy.Therefore anergy testing is not recommended in this population [54].
Treatment of MAC patients.Active drugs include the macrolides (azithromycin and clarithromycin, and
amikacin)[62].Therapy initially should include a macrolide and ethambutol. A third agent, such as rifampin or
ciprofloxacin, can either be included in the initial regimen or added if there is slow response. The addition of
amikacin as fourth agent may be needed in some patients who fail to respond or who relapse [63].Testing of
isolates for clarithromycin or azithromycin resistance is recommended for all clinically significant isolates[64].
VIII.Conclusion
Tuberculosis is an ancient disease of mankind with risk for death in HIV-infected patients with TB is
twice that in HIV-infected without TB. The tuberculosis control is the early diagnosis, treatment of TB among
HIV-infected patients and prevention oftuberculosis transmission in the community. DC guidelines for the
diagnosis, treatment and prevention of tuberculosis is useful.
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